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Blood and nutrition, endocrine
disturbances, and renal disease
Disorders of the blood
• It is well known that lesions of the oral
mucosa may occur in patients with
abnormalities of the blood. In particular,
the appearance of glossitis or angular
cheilitis in anaemic patients has often
been described
Anaemias
• The characteristic feature of anaemia is a
reduction in the level of haemoglobin,
which is usually accompanied by a
decreased number of erythrocytes. The
red cells (erythrocytes) are the circulating
cells predominantly concerned with the
transport of oxygen to the tissues by
means of the iron-containing substance
haemoglobin within them
Most of the Pt
• The great majority of these patients are
suffering from anaemias of various kinds
and, hence, the major interest is centred
on this group of conditions, but it must be
borne in mind that abnormalities of the
white cell and platelet components of the
blood may also be reflected in oral
changes.
Types of Aneamia
• Megaloblastic anaemias
• Iron deficiency anaemia
• Haemolytic anaemias
• SICKLE-CELL DISEASES
Megaloblastic anaemias
• Vitamin B12 or folic acid deficiency are the
most common causes of anaemias with
macrocytosis. Pernicious anaemia is an
autoimmune condition causing atrophy of
the gastric mucosa (atrophic gastritis) and
consequent failure to secrete intrinsic
factor due to an anti-intrinsic factor
antibody.
• Therefore, in patients with this condition
antibodies to intrinsic factor may be
detected in the blood. More complex
malabsorption syndromes may also occur,
involving failure to absorb not only vitamin
B12, but also folic acid and iron
compounds. The term megaloblastic
anaemia refers to the change in size and
structure of the basic marrow cell from
which the erythrocytes are derivedâ
Iron deficiency anaemia
• A much more common cause of anaemia
than failure to absorb vitamin B12 or folic
acid is iron deficiency, which leads to
inadequate haemoglobin synthesis. The
deficiency may be due either to
inadequate intake of iron or to excessive
blood loss as in menstrual abnormality or
gastrointestinal bleeding
Haemolytic anaemias
• There is a further group of anaemias, the
haemolytic anaemias, in which the
essential abnormality is an increase in the
rate of erythrocyte destruction. Under
normal conditions, the red cells last for
about 100 days, but in haemolytic
anaemias their life may be reduced to only
a few days.
• Haemolytic anaemias may be due to an
intrinsic defect or may be acquired—an
important, although relatively uncommon,
cause of the acquired form being the effect
of some drugs
• (However, the most important haemolytic
anaemia in terms of dental practice is
sickle-cell anaemia, although this condition
is somewhat different from the others
under consideration in that its major
significance to the dentist is not in the
production of oral lesions.
SICKLE-CELL DISEASES
• sickling may occur in conditions of low
oxygen tension and, if this change does
take place, the oxygen-carrying capacity of
the blood is greatly reduced with the
consequent possibility of anoxia in the
patient
Oral signs and symptoms of
haematinic deficiencies
• Glossitis
Smooth, depapillated tongue (iron
deficiency)
Raw, beefy tongue (vitamin B12 and
folate deficiencies)
Oral candidosis (including angular cheilitis)
Exacerbation of RAS
Plummer–Vinson syndrome (iron
deficiency
Orofacial manifestations
• Orofacial manifestations of sickle-cell
anaemia include prominence of the
maxilla and mandible and orofacial pain.
These occur as a result of marrow
hyperplasia and expansion of the marrow
space due to a longstanding haemolytic
anaemia. Destructive osteomyelitis is a
recognized complication of dental infection
in sickle cell disease
Oral signs and symptoms in
anaemias
Management of patients with
anaemias and haematinic
deficiencies
• Ninba waayihiisaa Waala lootumaa
Xalka
• In the majority of the patients described,
treatment of the underlying haematological
deficiency leads to a rapid resolution or
improvement in the oral symptoms. In
patients with longstanding latent iron
deficiency, however, the response may be
a slow one
Leukaemia
• Leukaemia represents a malignant
proliferation of white cells, replacing their
normal development in the bone marrow. This
process may affect any of the white cell
strains, but the most usual forms are
lymphocytic, monocytic, and myeloid,
depending on whether lymphocytes,
monocytes, or granulocytes are involved.
Each of these forms of leukaemia present
either in an acute or a chronic form
oral signs
• It is not uncommon for oral signs and
symptoms to be the first indication of the
presence of leukaemia, particularly of one
of the acute types The gingivae are
frequently involved with a hyperplastic
gingivitis. The hyperplastic gingivitis
results in fragile red spongy gingivae that
bleed spontaneously or following slight
injury.
Orofacial manifestations of
acute leukaemia
• Spontaneous haemorrhage for gingivae
(reduction in platelets)
Oral purpura and petechiae
Gingival swelling (leukaemic infiltration)
Oral ulceration (leukaemic deposits,
infections, haematinic deficiencies)
Mucosal swelling and loosening (exfoliation) of
teeth (leukaemic deposits)
Opportunistic infections (e.g. herpes, Candida)
Lymph node enlargement *N.B.
Chemotherapy to treat leukaemia may also
produce oral side-effects
Leukaemia
haemorragic
In more advanced cases
• In more advanced cases of leukaemia,
oral ulceration is very common. The
ulcers, produced by the breakdown of the
tissues overlying deposits of leukaemic
cells, may be large, painful, and difficult to
treat. The maintenance of oral hygiene
may be of great help in reducing the
distressing oral symptoms in these
patients
Leukopenia
• Leukopenia represents a fall in the white
cell content of the blood. This may be a
spontaneously arising condition, but may
occur also as a response to drug therapy.
Carbamazepine has been associated with
severe haematological effects, including
leukopenia and aplastic anaemia
Leukopenia
• Leukopenia may also occur as a transient
stage in the development of leukaemia
and other diseases affecting the bone
marrow. It may also result from
autoimmune disorders such as systemic
lupus erythematosus (SLE) and viral
infections; particularly HIV/ infections.
clinical presentation
• the most usual clinical presentation is of
agranulocytosis. This represents a
reduction in the number of granulocytes
formed in the marrow and circulating in the
blood. The effect of this is to increase the
susceptibility of the patient to infections of
various kinds
In the case of the oral mucosa
• In the case of the oral mucosa this may
lead to widespread infection and ulceration
of all parts of the mucosa. These changes
may not be dissimilar to those occurring in
leukaemia
Platelet abnormalities
• When the function or the number of the
platelets in the circulating blood is
reduced, there is a tendency for
spontaneous haemorrhage to occur within
the tissues. This may well show initially in
the form of petechial haemorrhages on the
oral mucosa and these are, in fact, a wellknown sign of early immune
thrombocytopenia
In leukaemias
• In leukaemias of various kinds, both
platelet function and numbers are greatly
reduced, and haemorrhages of mucosa
and skin may therefore be an early
warning sign.
• It is advisable to carry out a full blood
screen, including a platelet count, on any
patient with otherwise unexplained areas
of haemorrhage affecting the oral mucosa.
It should be remembered, however, that
transient haemorrhages of this kind may
occur on the soft palate in patients with a
severe cold
Oral medicine patients who
should be considered for an
extended haematological
examination
• Patients with recurrent aphthous stomatitis
(RAS)
Patients with a persistently sore and/or dry
mouth
Patients with oral lesions with an atypical
history or unusually resistant to treatment
Patients complaining of a sore or burning
mouth or tongue, or abnormal taste
sensation, even though no mucosal
• changes can be seen
All patients with persistent oral and
orofacial candidosis
Patients showing abnormalities following
an initial screening
Disorders of nutrition
• The integrity of the oral mucous
membrane is maintained by a wideranging complex of factors, including those
dependent on adequate nutrition. The
significance of iron metabolism and
associated factors
Nutritional deficiencies
• A wide range of conditions that depend on
the absence or reduction of certain
specific nutritional factors, particularly
vitamins, conditions are now rarely seen
under European conditions, although
It should be remembered
• It should be remembered that a nutritional
deficiency may occur in three ways: (1) as
a result of reduced intake; (2) as a result
of faulty absorption or metabolism; and (3)
as a result of increased excretion. The
relationship of iron deficiency anaemia to
these three factors is a good and simple
example.
Endocrine disturbances
• In general, changes in the oral mucosa
dictated by endocrine abnormalities are
not common. Perhaps the most frequently
cited changes are those due to the
endocrine disturbances found in normal
life—especially during pregnancy, and at
the menopause.
It should be remembered
• It should be remembered that endocrine
disorders are highly complex and often
involve a number of systems because of
the feedback mechanisms that control the
endocrine system as a whole.
It is,difficult
• It is, therefore, often difficult to determine
the exact effect of a single endocrine
abnormality on any structure. Endocrine
disorders affecting bone and teeth
(gigantism, acromegaly, and
hyperparathyroidism
laakin
• Hypoparathyroidism resulting from
parathyroid or thyroid surgery has no
particular effects on the orofacial tissues
but results in a low serum calcium. Tetany
is the clinical manifestation of reduced
serum calcium.
Normal endocrine changes
Pregnancy
• During pregnancy, the hormonal changes
that occur may have the effect of
exacerbating a previously existing chronic
gingivitis that may have been previously
symptom-free and unrecognized
Theresulting gingivitis
• Theresulting gingivitis is essentially
hyperplastic, although there is minimal
proliferation of fibroblasts. The most
marked proliferation is of capillaries and
this leads to the typically purple coloration
of the gingival papillae (Fig. 13.4). These
papillae tend to be fragile and may bleed
at the least injury
• Because of the presence of false
pocketing and bleeding, stagnation and
secondary infection may occur, and may
lead to halitosis
Pregnancy gingivits
Adrenocortical diseases
Addison's disease
• Addison's disease is the result of lack of
function of the adrenal cortex, usually the
result of an autoimmune disorder, but with
other possible aetiologies
• The oral change of significance in
Addison's disease is melanotic
pigmentation of the oral mucosa, which
may include the buccal mucosa, gingivae,
and palate
Hypothyroidism
• Hypothyroidism in adults is often
autoimmune but may occur as a
consequence of excessive removal of the
thyroid gland to treat hyperthyroidism.
Acquired hypothyroidism (myxoedema)
manifests as weight gain, inability to
tolerate cold, dry skin, loss of hair, and a
slowing down of activity and mental
processes
Hypothyroidism
• Hypothyroidism is associated with an
impaired immune mechanism and oral
candidosis may be the result. There is
often a relationship between pernicious
anaemia and hypothyroidism—possibly in
the family if not in the individual.
Congenital hypothyroidism
• Congenital hypothyroidism (cretinism) is
characterized by dwarfism and mental
retardation. Orofacial signs include
enlargement of the tongue , defective
facial development, and delayed eruption
of the teeth
Diabetes mellitus
• Diabetes mellitus is a common endocrine
disorder that occurs as a result of a
deficiency of insulin or resistance to
insulin. Two clinical types are recognized:
juvenile onset (insulin-dependent, type 1)
and maturity onset diabetes (type 2).
Diabetes mellitus has no
• Diabetes mellitus has no specific oral
signs or symptoms. However, possibly
because of the general lack of resistance
to infection of the diabetic patient,
periodontal disease processes may
become exaggerated It is not uncommon
to find that an undiagnosed diabetic
presents with advanced periodontal
disease.
, the dental surgeon must
always remember
• The principles of treatment of this are
simply those of periodontal treatment in
the nondiabetic patient. However, in this
and in all other treatment, the dental
surgeon must always remember that the
diabetic patient is more than normally
susceptible to infection
Oral features of diabetes
mellitus
• Dry mouth
Compromised periodontal health*
Oral candidosis
Glossodynia
Lichenoid drug reactions (oral
hypoglycaemic drugs
• *Depends on oral hygiene.
Renal disease
• Renal disease is of great significance in
oral medicine and general dental practice.
Oral changes occur not only as a result of
chronic renal failure but also as a
consequence of the medical management
of renal disease. The dental management
of patients with renal disease may also
need to be modified to prevent
complications.
Chronic renal failure
• Chronic renal failure (CRF) is irreversible
deterioration in renal function. When
plasma creatinine persistently exceeds
300 µmol/l (normal range 80–120
µmol/l), there is progressive deterioration
in renal function, irrespective of aetiology.
glomerular filtration rate
When the plasma creatinine reaches 1000
µmol/l, dialysis will be required. The
glomerular filtration rate (GFT; normal, 120
ml/min) measures renal function.
Progressive impairment in function of the
kidneys leads to the development of the
clinical syndrome of uraemia
Orofacial manifestations of
chronic renal failure
• Chronic renal failure and its resultant
uraemia cause a number of physiological
changes that can cause oral symptoms
Orofacial manifestations of
chronic renal failure
• Dry mouth
Mucosal ulceration
Bacterial and fungal plaques
Pallor of the mucosa (anaemia)
Oral purpura
White plaques (uraemic stomatitis)
Giant cell lesions—osteolytic lesions in
jaws
Giant cell lesions of the jaws
• Giant cell lesions of the jaws may occur as
a result of hyperparathyroidism secondary
to renal failure (or prolonged dialysis) and
give rise to oral lesions or osteolytic
lesions in the bone. Patients with CRF are
now treated with potent alphahydroxylated vitamin D supplements to
prevent secondary hyperpathyroidism
• Great care must be taken when
prescribing drugs for patients with renal
failure and the safest drugs to use are
those that are metabolized primarily by the
liver. Dosages of other drugs need to be
adjusted to compensate for decreased
renal excretion
Renal transplant patients
• Renal transplantation, either from a tissuematched cadaver or close relative, offers
the best hope of a normal life. However, it
is not without problems, mainly due to the
side-effects of immunosuppressive
regimens given to prevent rejection of the
transplanted kidney
doses of corticosteroids
• In the past large doses of corticosteroids
gave rise to considerable short- and longterm problems (see Chapter 3). Renal
transplant patients pose a number of
dental and medical management problems
Oral complications of renal
transplantation
• Drug-induced gingival overgrowth
(hyperplasia)
Bacterial and fungal plaques
Increased incidence of oral malignancy
(reported)
Oral candidosis
Herpes simplex infections (secondary)
Oral complications of renal
transplantation
Immunodeficiency,
hypersensitivity, autoimmunity,
and oral reactions to drug
therapy
• Bacdaa dhuuqsoy
• Baalweynta Yaan lagaa boojeynine!!!
Immunodeficiency
• Immunodeficiencies may be classified as
primary or secondary. Primary
immunodeficiencies represent an intrinsic
failure in development of one or more
parts of the immune system and are often
genetically based. They can be
predominantly B- or T-cell defects, a
combination of both, or due to a selective
immunodeficiency (for example, IgA
deficiency
Afew individuals are born
• Afew individuals are born with gross
primary immunodeficiencies. These may
result in life-threatening conditions and the
affected individuals tend to die young,
often as a result of recurrent infections.
Candida infections are often predominant
in these patients (see Chapter 4) who
suffer from aphthous-like ulceration and
herpes infections. They are also more
susceptible to periodontal disease.
IgA
• IgA deficiency is relatively more common
than other primary
immunodeficiencies—levels of IgA are
decreased in both serum and saliva.
Secondary immunodeficiency
• The immune system is composed of a
variety of cells, especially white blood
cells, and proteins, for which one of the
principal functions is microbial defense. A
deficit in the immune system can therefore
lead to unusually severe or uncommon
recurrent infections. Immune deficits
(immunodeficiency) may be primary or
secondary..
Secondary immune
• Secondary immune deficiencies or
acquired deficiencies, more frequent than
primary immune deficiencies, are
problems of the immune system that are
not genetic and which are caused by
external factors
An example of a secondary
immune deficiency: AIDS
• The most well-known example of a
secondary immune deficiency is the
immunodeficiency caused by the human
immunodeficiency virus, or HIV. HIV
attacks certain cells in the immune system
and prevents them from carrying out their
proper functions against microbes
• . When the immune system is sufficiently
weakened, infected people catch atypical
and severe infections. This is then called
the Acquired Immunodeficiency
Syndrome, or AIDS. AIDS at this time is
often treated by a specialized
multidisciplinary team.
What are other causes of
secondary
immunodeficiency?
• Dhantadu Dhimataye
• Dhulkey kudhacdee
• Dhantada Dhulka maad kaqadaney
Other causes
• Other causes of secondary
immunodeficiency include: severe
malnutrition, certain chronic diseases such
as diabetes, immunosuppressive
medication or chemotherapy, certain
cancers such as leukemia, and the
absence of the spleen (sometimes the
spleen must be removed because of
trauma, for example).
How are secondary
immunodeficiencies treated?
The treatment depends on the severity in
the deficiency of the immune system.
Treatment of the underlying cause often
leads to improvement of the condition.
Patients are typically followed by their
usual physician: the allergist-immunologist
may be consulted in certain cases.